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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
Listening to Words, Hearing Feelings: Links Between Eating Disorders and Alexithymia
By F. Diane Barth, LCSW
Accepted for publication in The Clinical Social Work Journal
Even with all my languages, there still aren’t the right words.Julia Cho, The Language Archive
Catherine came to see me shortly before her 30th birthday. She was articulate and
intelligent and spoke such unaccented, clear English that I was surprised when she said that it was
not her first language and that she had only moved to the United States ten years earlier. She had
learned English as a child and seemed both proud and not completely sure of her fluency. This
piece of information would be important in the course of our work. She also said that she had
struggled with her weight all of her life and had lost seventy-five pounds in the past year. But she
was not coming to see me about her weight. She made it clear that she had things under control in
that arena and indicated that she did not need – or want – my input about it.
She had come to therapy for help with a “situation.” She had become involved with a
man named Samuel, and although the relationship was not sexual, it was more intimate than most
of her connections to other people. Catherine’s was a solitary life, with very few relationships
managing to get through her protective boundaries. Even the very limited link with Samuel had
been disruptive to her feelings of well-being, but until recently it had been more or less
manageable. Now it had become problematic. However, even though she understood that there
were multiple factors involved, when I asked Catherine to talk about the situation, she had
difficulty explaining anything other than the concrete facts. She wanted to give me some
background that she thought might help me understand something about the problem. She had
grown up believing that her family had little money. She had often felt deprived, not of basic
things, but of toys or electronics and other “extras” that her peers enjoyed. When she asked for
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
something that she saw at a friend’s house, she was told to wait for Christmas or her birthday,
only to be regularly disappointed by the gift that she actually received on those holidays. As an
aside she said that a previous therapist had linked this feeling of deprivation with her eating
problems, that her inability to control her eating had to do with that childhood feeling of being
repeatedly disappointed and unable to get her needs met. She also mentioned that buying clothes
had been traumatic, because she was bigger than many of her peers, and her mother had always
had difficulty finding clothes that fit her. Catherine believed that the larger sizes that she needed
were more expensive as well, adding to the pressure that she felt from very early to “be smaller.”
Her parents had both died more than ten years before our first meeting, her mother of a
long, drawn out illness that ended before Catherine was eighteen, her father a few years later. To
her surprise, they had actually accrued enough money to leave her a substantial inheritance.
Catherine used some of the money to pay for college, but otherwise continued to live as she had
when her parents were alive. After graduation she found a job and supported herself on the
income from it. No one but her family and her therapists knew about the inheritance until she told
Samuel about it. Shortly after this revelation, he began asking her for small loans. She had
gradually realized that he had no intention of paying her back. “It’s only a small amount,” she
said, “but I don’t want to keep giving it to him.” Catherine was puzzled that this bothered her so
much since, she reiterated, the amounts were always small. It should not have been “a big deal.” I
said that small things could still be big issues and Catherine sighed. When I asked if she could say
what she was feeling, she seemed surprised. She had not been aware of sighing and had no idea
what she was feeling at the moment. She said, “I don’t know what I feel. I just want to know what
to do.”
Such a statement can be troubling to a psychodynamically-oriented therapist, yet in my
experience, it is not uncommon for clients with eating disorders to have some variation of this
response – albeit not always put quite so bluntly – when asked about feelings. Research has
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
linked a number of eating disorders to alexithymia, that is, an inability to use thoughts and words
to help process feelings (e.g. see McClintock Greenberg, 2009; Pinaquy, Chabrol, Simon, Louvet,
& Barbe, 2003; Sands,2003; Zerbe, 2008). Yet I have found that many clients with eating
disorders, who seem to be able to talk about and understand their feelings actually suffer from a
subtle version of alexithymia. Especially in the case of verbal, intelligent clients like Catherine,
this inability may not be recognized, resulting in confusion and frustration for both therapist and
client. Understanding this subtle but powerful impact of alexithymia can enhance the use of both
psychodynamic exploration and non-psychodynamic tools for managing affect and changing
behavior. In this article I will address some of the ways that alexithymia can silently contribute to
the negative self-image, low self-esteem and poor body image associated with disordered eating
behaviors. I will discuss how this often hidden factor also impacts the ways in which even bright,
articulate and thoughtful clients are – or are not – able to regulate affects. Clinical material from
my work with Catherine will illustrate these issues. Although Catherine was diagnosed with
Binge Eating Disorder, I suggest that the question of alexithymia should be considered when
working with anyone with eating and body image issues.
Alexithymia
The term alexithymia is derived from Greek, meaning “without words for emotions.”
Initially applied to psychosomatic disorders (Sifneos, 1972), it is now viewed as a construct that
crosses diagnoses. Alexithymia today is generally used for clients who have difficulties using
language and words to process their emotions. Those who suffer from it also often have troubles
tolerating and managing feelings and therefore often have problems with both impulse control
and affect regulation (Barth, 2014b, 2015; Bruce, Curren & Williams, 2011; Castanier & Le
Scanff, 2009; Krystal, 1988; McClintock-Greenberg, 2009; Stewart, Svolensky & Eifert, 2002;
Woodman, Huggins, Le Scanff, & Cazenave, 2009). Both poor impulse control and difficulty
with affect regulation and self regulation are also often found in clients with eating disorders,
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
leading some clinicians and theoreticians to hypothesize a link between these disorders and
alexithymia (Fernández-Arandaa et al., 2006; Krueger, 2001; Pinaquy et al., 2003; Sands, 2003;
Zerbe, 2008). Krystal (1988) also notes that alexithymic individuals have limited “signal
emotions,” or warning signs that potentially difficult feelings are building, also often found in
clients with eating issues (2014b).
Perhaps not surprisingly, given that alexithymia involves difficulties with impulse control
and affect regulation, some observers consider it to be a normal component of adolescent
development (e.g. see Barth, 2015; Schore, 1994; Siegel, 2013). The development of difficulties
in this arena dovetails perfectly with adolescent vulnerability to problems with body image and
eating disorders (Gowers & Shore, 2001; Zerbe, 2008). The term “alexithymia” has often been
viewed as implying a difficulty naming feelings (McDougall, 1989). In my experience, however,
many clients suffer a more subtle form of alexithymia. Those with a wide range of eating issues
are often verbal, able to talk about feelings and even have good insight into the causes of their
behaviors. These verbal and cognitive strengths can disguise an inability to use their thoughts to
manage their emotions, leading to unrealistic expectations not only from a therapist, but also from
themselves. Their experience in therapy can echo a childhood precociousness that masked age-
appropriate developmental needs and turned into a lifetime of hiding vulnerability behind areas of
competence. As a result of this dichotomy, in many cases neither the vulnerabilities nor the
strengths have been integrated into a more complete and cohesive sense of self. Self-criticism and
negative self-image resulting from this misunderstood duality is often concretized in a negative
body image. A sense of falseness, of a hidden badness, can be part of this split between their
obvious abilities and pockets of originally age-appropriate developmental “lags.”
While these clients often struggle with unformulated and/or dissociated emotions and
thoughts (e.g. Bromberg, 2001; Petrucelli, 2015; Sands, 1991), the unrecognized presence of
alexithymia can interfere with attempts to integrate the psychological meanings of these
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
experiences. Emotional and historical causes of body dysmorphia and problem eating, as well as
of anxiety about dependency needs, fears of rejection and loss of support and more may all be
clearly verbalized and understood within a historical context, without leading to behavioral or
dynamic change. Indeed, because of the gap between the words and the actual feeling experience,
these explanations can reinforce existing feelings of inadequacy, increase the need for affect
regulation and self-soothing provided by eating behaviors, and lead to feelings of frustration and
helplessness for both client and clinician. Alexithymia is one reason that CBT and therapeutic
interventions directed at affect regulation and mindfulness can be more effective than
psychodynamic exploration; but in my experience, the presence of alexithymia is also a reason
that it is even more productive to integrate such interventions with a psychodynamically-based
therapeutic relationship and, eventually, with psychodynamic understanding (Barth, 2014a,
2014b).
Alexithymia and Resistance
Alexithymia can make it appear that bright, verbal clients are stubbornly clinging to
symptoms and resisting change. Yet a focus on the concrete is not simply an attempt to avoid the
pain of intolerable feelings, but is also a way of holding a fragile, poorly integrated self together.
Kohut (1971) has described this phenomenon in hypochondria, which sometimes accompanies
eating disorders. Obsessional focus on the body as well as cutting and other self-harming
behaviors that also are frequently found in individuals with some eating disorders can also be
explained as attempts to maintain self-cohesion. Williams and Wood (2009) have suggested that
these behaviors may be a concrete way of actually feeling something in their bodies. They may
also be a way of physiologically experiencing the difference between what is inside and what is
outside of themselves and, as Stolorow (1975) puts it, “re-establishing a sense of existing as a
bounded entity, a cohesive self.” (Stolorow, 1975, p. 443).
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
For these clients, feelings often have a physical instead of an emotional presence.
Because they seem to reside in the body, it is the body that has to be soothed. Physical actions
like use of drugs, alcohol, sex, binging, purging, over-exercise and starvation can be attempts to
not only maintain self-cohesion but also soothe the body self where the feelings are. Yet while
these activities may provide momentary solace, they often increase feelings of shame, discomfort,
and low self-esteem, thus undoing the positive effects and requiring further and often greater
solace-seeking behaviors. Negative body image both represents these intolerable emotions and
also leads to further attempts to manage them physically. With clients who are verbal and appear
to be insightful, it would seem that understanding the meanings of the behaviors would help them
make the changes necessary. Further, it often seems to clinicians that these clients should be able
to understand the harmful consequences of their bodies, and should be able to change as a result
of education about the dangers of the behaviors. Over the years as I have listened to my own
clients, as well as to colleagues and supervisees describe their frustration and confusion when
their clients continue to engage in these behaviors even after seeming to understand these
dangers, I have found that alexithymia helps to explain what is happening when these
interventions do not lead to change.
What may appear to be intentional resistance can be understood through the lens of
alexithymia as an inability to use language to manage both the “as-if” frame of dynamic
exploration and also the feelings that are stirred up by these explorations. Literal thinking can
lead to both self-blame and parent-blaming when understanding historical antecedents is expected
to both explain and undo all complex, painful and confusing feelings. A wordless fear of
dependency, a sense of possibly exploding or imploding, and a dread of being both overwhelmed
by feelings that cannot be managed and sucked into a black hole of emptiness can interfere with a
client’s ability to join fully with a clinician, no matter what approach or technique is offered. The
behaviors that are in question become even more necessary for soothing. The danger of losing
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
them also increases the need. It is for these reasons that I encourage the use of multiple modalities
with such clients. In this stage of fear and anxiety about loss of powerful and important self-
soothing tools, cognitive behavioral, mindfulness and suggestions for physical ways of managing
feelings can be key.
Clinical vignette: The alexithymic gap between words, thoughts and feelings is, I would
suggest, one of the reasons that Catherine’s understanding of the psychological link between
childhood feelings of deprivation and her eating behaviors had never had much of an impact on
her eating behaviors. The thoughts made sense to her, but they did not help her manage her
feelings. Nor did they help her keep off the weight she had lost, which she gradually re-gained in
the first year of our work together. Catherine sometimes sounded as though she was unwilling to
explore her feelings, but she was not being unreasonable or defiant. She was simply
communicating that talking about her emotions had little meaning to her. Certainly, she knew that
she felt. But the idea of trying to explore or open up her emotions was like asking her to begin to
speak in an unknown language. This was a meaningful analogy for understanding Catherine,
although not useful as an interpretation or explanation of symbolic meaning. She was fluent in
three languages and learned a fourth while we were working together. Language was, not
surprisingly, important in her family, and Catherine often proudly noted that she spoke English
better than other family members. Yet she was susceptible to any potential criticism of her
facility with the language. For example, she had an amazing grasp of colloquial English, but she
was always hyper alert to the possibility that she had misused a phrase or was not familiar with a
particular structure used by a colleague. Her self-esteem and even her sense of who she was could
change based on how well she felt she had spoken English on a particular day or in a given
situation, as well as by how others responded to her word choices and sentence structure.
I gradually came to understand that neither her keen intelligence nor her love of language
made it possible for her to use words to process her feelings. For instance, she understood when I
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
said that she ate to soothe herself, but this did not make her feel any more empathic to herself. In
fact, she was extremely critical of this behavior and felt that she should stop now that she knew
what she was doing. She also could put into words that her attitude towards her body was partly
related to beliefs expressed both in her family and also in the culture in which she grew up, where
thinness represented social status and success. But this verbal knowledge did not diminish either
Catherine’s extremely critical attitude towards her body or her ongoing use of food for self-
soothing. Just as with her use of English, Catherine was hyper alert to and very critical of her
body from the point of view of an outside observer. Her feelings about her physical self were
almost always based on some sort of external measures – the actual number in pounds of her
weight, the size clothing she could wear, and whether or not she could fit comfortably into a seat
on public transportation or in a theater. If one of these numbers went down, she could feel good.
If they went up, she was fat, bad and a failure in every way possible.
Catherine looked at her feelings from the outside as well. She was able to name feelings,
and she clearly experienced them, but she could not describe how they manifested themselves
either in her body or in any of the other affectively meaningful ways that are key to the process of
metabolizing and managing affect (see Fonagy, Gyorgy, Jurist, & Target, 2003; Schore, 1994,
2003; Siegel, 1999, 2013). I learned in those early sessions that the language that had the most
affective resonance for Catherine involved words that described boundaries and limit setting.
When she had troubles setting limits with herself or with someone else, she often needed help
spelling out the limit and thinking about where she stopped and the other person began.
Sometimes this was literal – what were her physical limitations in a particular situation? Where
did her body stop? Where did she overflow into someone else’s space? Where was the other
person’s body encroaching on hers? Sometimes, much later in the work, the ideas could be more
abstract. We could talk about personal space and emotional need (although she still preferred that
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
I not use the word “feeling.”) But in those early sessions, we worked on establishing the concrete
specifics of boundaries, and her right to have them, in particular with Samuel.
In response to her question about what to do, I asked Catherine if she knew what she
wanted to do. She said that she wanted to stop giving Samuel the money, but she did not think she
could. I asked if felt that she had a right to declare that the money was hers? She shook her head
“no.” I said that that would make it hard to limit what she gave him, and she started to cry. “I
can’t,” she said, but it was not until many months later that we were able to find a way to talk
about what was going on at that moment. Catherine had plenty of words, but none that would
help her to adequately describe what she was experiencing, even to herself. Nor were there words
that helped her integrate what she wanted, needed and felt with what she could actually do. Her
thoughts did not seem to communicate with her feelings.
Thoughts and Feelings
This failure of communication between feelings and thoughts is not unusual in clients
with alexithymia. Thus, like Catherine, many individuals with eating disorders may easily talk
about feelings but not be able to describe what the feeling they are talking about feels like.
Hagman (2014) suggests that we cannot have thoughts without feelings or feelings without
thoughts, so that in most of us left and right brain are always in communication with one another,
even when one side is stronger or better developed than the other. When alexithymia is present, it
appears as though the communication between the different parts of the brain gets scrambled or
diverted. Words and thoughts do not help a person with alexithymia decipher what they are
feeling, and feelings do not enrich thoughts. Processing both aspects of experience can become
more and more difficult, especially as symptomatic behaviors become entrenched as a path
between the two.
Alexithymia can make it hard for a client to communicate with her or himself. It also
makes it difficult for a clinician and a client to hear and speak to one another, no matter how
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
carefully they listen or how much work they put into choosing the right words. When it is present,
a therapist and a client may speak the same words but not give them the same meaning. Like a
precocious toddler who functions above his or her developmental level, clients with alexithymia
often have significant strengths accompanied by lacunae of underdeveloped aspects of self.
Alexithymia represents an often-unrecognized gap between their capacity to talk intelligently
about themselves and their ability to use these words to process their feelings or change their
behaviors. This mismatch between ability to “understand” and capacity to integrate the
understanding into genuine self-awareness leading to behavioral change can contribute to a
frustrating therapeutic experience that echoes a lifetime of relationships. A concomitant sense of
disappointing others and of not living up to their own expectations can then be reflected in
defensiveness, isolation, feelings of helplessness and hopelessness and self-denigration.
Awareness of the presence of alexithymia can help a clinician avoid repeating this relational
dynamic, or when it does occur, address it in such a way as to ameliorate the negative impact.
Clinical vignette: Like many of the analysands described by Kohut (1971, 1977)
Catherine needed words to exactly reflect her experience in order for them to have meaning for
her. For instance, at one point, having learned that Catherine was having troubles spending the
money her parents had left on herself, I said that some people see such a legacy as a connection to
their parents, and do not like to spend it because they do not want to lose that connection.
Catherine looked blank, then shook her head and said, “I don’t agree.” She did not mean that she
thought it impossible for anyone else to feel the way I had described. She was simply expressing
the fact that it was not how she felt. This way of communicating her feelings – to make them a
matter of opinion, or of fact – was telling. Renik (2006) points out that it can be useful for
therapists to share our thought processes with some clients. In the earliest sessions I learned that
Catherine found it helpful when I “thought out loud” – that is, when I shared with her how I got
to a particular idea or concept. This was made obvious when we began talking about boundaries.
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
When Catherine began to cry about not being able to tell Samuel “no,” I said that I thought she
was having troubles with boundaries. She was not sure what I meant, so I shared some of my
thoughts about limit-setting. I told her that I thought that boundaries were very important to our
ability to feel safe and comfortable. I also shared that boundaries could be hard to set, especially
when others did not seem to agree about where the limits should be.
Links between eating disorders and difficulty with limit-setting have been identified by
numerous authors (e.g. Arkell & Robinson, 2008; Levander & Werbart, 2012; Telch, 1997). I
would learn that Catherine had, throughout her life, fluctuated between almost boundless binge
eating and the kind of rigid diet regimen that she was on at the moment. But in that early session,
I simply said that I thought Samuel was breaching her boundaries and that I thought that was
problematic and not just for her, but for anyone. I reiterated that many of us have difficulties
setting limits, for many different reasons.
Taking a cue from the fact that she was nodding enthusiastically, I asked if she could talk
about what she was thinking about. (I learned very quickly that whether I asked about feelings or
thoughts, Catherine answered with thoughts. I therefore tried to use the word “thoughts” while I
worked to find some ways to help her actually make contact with some of her feeling
experiences.) She said that her parents had set strict limits with her and her brother, but they had
not believed in boundaries that went the other way. “We kids didn’t get to set boundaries,” she
said. “We just did what we were told.” I said that I thought that was what was making it hard with
Samuel. She was doing what she was told – but I wondered if she could try to do what she
thought was right instead. She said she was not sure what that was. I teased out with her that she
did not want to give him free access to her money and then I repeated what we had just said.
Once I had said it back, she said, “Oh, okay, so I should just tell him that?” I asked what she
thought would happen. “What if he doesn’t listen?” she said.
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
In that session and the one following, we did some role-play, with Catherine trying out
different ways to respond to Samuel’s demands and counter-demands. I had no idea what to
expect from this interplay, and was surprised when, in the next session, she told me that she had
explained to Samuel that he could not have anymore of her money, and he had accepted the limit
without question, without anger, and without any other apparent negative repercussions. When I
asked how she felt about it, she grinned widely. “I think it’s great!” she said.
Proprioceptive Awareness
Understanding some of the family dynamics around food and eating, physical appearance
and weight, boundary setting, and other concrete symbols of status and worth helped us find ways
of talking about why Catherine was so critical of and ashamed of her body. But external gauges –
her weight, her size, her precisely correct use of another language – were ways for Catherine to
regulate affect and in particular affect surrounding self-esteem. Catherine had little information
about what it actually felt like to be in her own body, and less about what her body actually
looked like. Body dysmorphia and self-criticism for bodily imperfections are common symptoms
in eating disorders. What is also common is a lack of proprioceptive awareness – that is, an
inability to recognize bodily sensations in anything but their strongest forms (Eshkevari, Rieger,
Longo, Haggard &Treasure, 2012). The lack of proprioceptive information has also been found in
clients with alexithymia. For example, Castanier & Le Scanff (2009) describe studies in which
respondents spoke of only being able to feel something in their bodies when they were engaged in
dangerous or risky behavior.
I would suggest that this lack of proprioceptive awareness causes the common failure to
“see it coming” (when the “it” is either a feeling or a behavior) in individuals with eating
disorders. The frequently reported sensation that a need to binge, exercise, cut or burn oneself, or
even a sudden awareness of having gained a great deal of weight “comes from out of nowhere”
seems to me to be related to a failure of “signal emotions,” which Krystal (1988) calls the small
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
indications that powerful or unpleasant feelings are beginning to build. Because individuals
suffering from alexithymia have no warning until emotions “hit” them full force, and therefore no
way of modulating their feelings in earlier, more manageable stages, they often need body-based
methods for self-soothing, such as drugs, alcohol, sex, extreme physical activity, and binging,
purging or severely restricting food intake, and self-harm.
I have found that it can be useful to acknowledge and sometimes even explain the lack of
proprioceptive information accessible to clients with eating disorders. Mindfulness practices and
a number of cognitive behavioral techniques can provide useful tools for making connections
between thoughts, emotions, and physical sensations. This work often goes slowly and is most
useful when done within the context of a safe relationship in which feelings of inadequacy and
self-criticalness about not being able to make contact with bodily-based information can be
defused. A number of integrative authors, including (Barth, 2014a, 2014b), Connors (2006),
Frank (1999), Wachtel (1997) and Zerbe (2009), offer suggestions for therapeutic interventions
that help clients develop both proprioceptive awareness in combination with insight. Some of
these suggestions are for mindfulness and breath work, cognitive behavioral techniques, and long
term talk therapy. It can also be useful to help clients to focus on and learn to recognize hints
from their bodies that will help them build both signal emotions and tools for managing those
feelings.
In my experience, these interventions are most successful within the context of a
supportive, interested and nonjudgmental therapeutic relationship. A clinician can encourage a
client to pay attention to small details of bodily sensations and help them find words for those
sensations. For instance, many clients cannot say where in their bodies they actually feel hunger
or how they know what they feel. A clinician who recognizes the presence of alexithymia will
look for ways to enhance the communication between the part of the brain that “knows” and the
part that “feels” (Hagman, 2014). Our bodies have many ways of communicating hunger – not
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
simply in our stomachs (which is where we often think the feelings reside), but in our throats,
mouths and even thoughts. Although popular weight loss techniques encourage dieters to ignore
“mouth hunger,” I find it more useful to consider it a valuable piece of information.
Clients are also often surprised when I suggest that thoughts can be an early signal that
they are getting hungry. Images of food and thoughts about eating can be indications that their
body needs food. Such signals are meaningful and should be acknowledged. The part of the brain
that uses words has to accept what the part that registers feelings is communicating. Only then
can meanings be deciphered and emotional needs be differentiated from physical hunger. Only
then can appropriate action be taken. Once clients begin to listen to thoughts as having physical
meaning, they can begin to pay attention to other ways that they communicate feelings to
themselves and to others. Borrowing from Sullivan’s (1953) detailed inquiry, I ask clients to try
to tell me tiny details about thoughts and bodily experiences related to feelings. If someone tells
me they are anxious, I ask them to try to say how they “know” this is what they are feeling. What
are the clues that it is anxiety and not sadness? How can they tell they are anxious and not happy?
This is not an easy task, even for someone without alexithymia. Since so many of our emotions
are felt in our bodies, it can be helpful to ask about bodily sensations. “Do your hands feel a little
sweaty?” “Is your heart beating more rapidly?”
Helping clients learn that their bodies are often full of information about their emotions
can also help them feel less critical of themselves for the sometimes overwhelming need to soothe
their bodies. I explain that they use food to soothe themselves from the inside out. I also suggest
that the ability to hear and respond to the physical manifestations of their feelings is adaptive. It
will also be an important aid in the process of learning other ways to soothe themselves. In the
same vein, I also encourage clients to pay attention to their thoughts. Rather than view thoughts
as defensive or as “intellectualization,” I work with clients to see their thoughts as reflections of
feelings. Valuing thoughts not simply for themselves, but as links to feelings helps to reinforce a
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
strength that many of these clients bring into therapy – their minds. That strength can then be
utilized in the work of building a greater capacity to tolerate and regulate their affects, which will
gradually lead to a more cohesive and integrated sense of self.
Countertransference
The progression to self-awareness and insight, which is not speedy in many therapeutic
experiences, can be both slow and also concrete when someone has alexithymia. It is not
uncommon for a clinician to become irritated with articulate and intelligent clients like Catherine
who seem to be almost intentionally negativistic or resistant. Such countertransference frustration
can mirror lifelong experiences of frustration from others who saw their strengths and could not
understand why they were not living up to their abilities. Like the precocious toddler with pockets
of age appropriate, undeveloped abilities, they are blamed for something that is not in their
control. Often actually having been such advanced or gifted children, alexithymic individuals
may both internalize the criticism and simultaneously project their criticism outwards. Defenses
of projection and projective identification may lead to a therapist’s feeling criticized and/or
denigrated by a client; but before the experience can be unraveled, work must be done to make
the feelings both tolerable and identifiable. I have found it helpful to recognize the adaptive
component of some of this apparent resistance (Barth, 2014a, 2014b), but the presence of
alexithymia adds yet another layer to this understanding. In some instances, referral to a
nutritionist, mind-body worker, psychopharmacologist or other adjunct clinician can be perceived
as “giving up” on the part of both therapist and client. But not only can their input aid in the
work, but a client’s reactions to the referral can sometimes add to an understanding of some of
dynamics that have remained out of awareness. This is how it happened with Catherine.
Clinical Vignette: After a series of painful events in her life, I became concerned about
Catherine’s growing and unremitting depression and referred her to a psychiatrist for an
evaluation and medication consult. I took it for granted that she understood that I was sending her
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
to the psychiatrist because of my concern, but I am not sure that I used the word “depression,”
since I had found that Catherine often felt both labeled and reduced by the use of diagnostic
terms. I did say that she seemed to be struggling with feeling unhappy and, when she immediately
became self-critical, I commented that she seemed to think it was her fault. She nodded and
brought up her anger at herself for regaining the weight she had lost prior to starting therapy.
Although we had talked about the possibility that her increased eating was her way of
trying to manage some of the painful feelings that were emerging as we talked about both her
history and her current struggles with difficult life events, she used this to underscore her flaws
and reinforce how bad she was. Still, she agreed to my referral, saying she thought it was a good
idea. After she met with the psychiatrist, she told me almost gleefully that he had told her that she
was seriously depressed, and that he would be depressed as well if he had to deal with all of the
things she had told him about. When I asked why she seemed so pleased, she said that his naming
it made it real, adding, “Otherwise, maybe I’m just making these things up.”
I wondered why, when the psychiatrist labeled her feelings, she felt heard and
understood, but when I labeled them, she often felt criticized and misunderstood. Not only were
there obvious transference issues (I believed she identified me with both her critical mother and
her own harsh superego), but because credentials were extremely important for Catherine, his
age, gender and the fact that he was a doctor would have given him a power I did not have. When
I tried to explore this with Catherine, she seemed to genuinely have no idea what I was referring
to. Although splitting and projective defenses were present, what seemed to be helpful to her was
my acknowledgement that I had not put either my understanding or my sympathy for her into
words as clearly as the psychiatrist had. I noted that the slow pace at which we progressed, which
I believe was not so much resistance but related to alexithymia, was difficult for her and
wondered if she blamed me for any of it. She responded with further criticism of herself for the
length of time therapy was taking.
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
It was helpful when I began to understand that, although her criticalness actually often
did appear directed at me, it was not about me, even in a projected form. Because Catherine’s
feelings only emerged in broad outline, irritability directed at another person was
indistinguishable from irritability directed at herself. Recognizing the presence of alexithymia can
help ameliorate such frustration in both participants. Helping an individual with alexithymia learn
to use language to process emotions is by definition often a slow and painstaking process, and
progress is often made in baby-sized steps.
Alexithymia, Trauma and Culture
Some theorists have suggested that alexithymia is the result of childhood trauma (e.g.
Krystal, 1988; Schore, 1994), and there is no question that Catherine suffered both in early
childhood and also in adolescence, with the serious illnesses and subsequent loss of both of her
parents. Yet I have worked with numerous clients who were unable to use language to process
emotions who had no history of emotional or situational trauma. I have come to believe that
alexithymia is to some extent a disorder of the current era, so much so that, without being named,
it has become integrated into popular culture. Spike Jonze’s 2013 movie “Her,” for example,
depicts a world in which people, having lost the ability to put their feelings into words, have to
hire someone else to figure out what they are feeling. Many clients who come for therapy these
days are like Theodore, the main character in Jonze’s movie, with highly developed verbal
abilities and an apparent capacity for insight, but without the expected concomitant of self-
knowledge helping them manage their affects (see Barth, 2015, 2014a, 2014b).
The work of therapy with individuals with alexithymia is multi-faceted. Research has
shown that a combination of techniques directed at self-regulation, management of affects and
behaviors, and harm reduction can be useful (Bruce, Curren & Williams, 2011; Castanier & Le
Scanff, 2009; Stewart, Svolensky & Eifert, 2002; Woodman, Huggins, Le Scanff, Cazenave,
2009). A growing body of evidence has also shown that a longterm psychodynamic therapeutic
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relationship is an important factor in a client’s ability to make changes that last (de Maat, de
Jonghe, Schoevers, & Dekker, 2009; Shedler, 2010). In my own experience with clients and
reports from supervisees, students and colleagues, I have found that combining a psychodynamic
approach with concrete tools for affect management and self-regulation is extremely useful. A
clinician’s ability to understand and respond to some of the dynamics, including the importance
of even maladaptive defense systems, without necessarily spelling them out directly to clients,
can make the slow progress more tolerable for both client and clinician. This is especially true in
the early stages of the work, but can continue throughout even a long therapeutic relationship.
Not all clients with alexithymia are alike. The symptoms of alexithymia cross diagnostic
categories, personality styles and character types. Thus there are no easy answers to how to work
with these issues. Some are very interested in understanding and exploring meaning, while others,
like Catherine, do not particularly find that avenue either interesting or useful. But in either case,
one of the tasks of a clinician working with clients struggling to find a link between words and
feelings, both emotional and physical, is to lend ourselves as tools in the process. Winnicott
(1965) suggests that analysts must take painful feelings and digest them for analysands, giving
them back only when a client is ready to absorb them and in quantities that a client can tolerate.
Alexithymia requires a similar treatment. We try to understand what a client might be feeling;
and then we try to assess what they can use of our understanding. In many cases, this means
translating our understanding of feelings into another language – that of the body, of the brain, or
of action.
Final Clinical Vignette: Over time, and with adjunctive assistance from a
psychopharmacologist, a nutritionist, and a variety of body workers, Catherine got better. As she
began to both know and feel her own boundaries, she also gradually found words that genuinely
helped her decipher, recognize and think about her feelings. It was clear that not only was I
important to her, but that our work together, despite a number of ups and downs in both the
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therapeutic process and also in her life, was important. During the time we worked together
Catherine earned a doctorate degree, wrote and published professionally, taught in her
professional field, and developed meaningful friendships as well as closer and more satisfying
relationships with members of her family. She also lost the weight she had gained in the early
stages of our work, and with support from an innovative nutritionist, was able to maintain that
weight loss, despite several more blows from life that might have made her – or anyone – give
up.
Summary
Alexithymia, or an inability to use language to process emotions, can be a subtle,
undiagnosed component of eating disorders even in articulate, intelligent clients. Historically the
term has been used to describe an inability to talk about or find words for feelings (Krystal, 1988;
Bromberg, 2001; McDougall, 1989), yet there is evidence that it exists in a wide range of
individuals with eating disorders (Barth, 2014a; Pinaquy et al., 2003; Sands, 1991) In this article
we consider the possibility that alexithymia exists but is often missed in clients with eating
disorders who are verbal and insightful. In these cases, when it is not recognized and incorporated
into the clinical work, therapy can simply reinforce a client’s lifetime habit of hiding areas of
vulnerability behind genuine areas of competence. Self-criticism and negative self-image
resulting from this dichotomy are often concretized in a negative body image. Unaddressed,
alexithymia can contribute to sense of falseness and hidden badness. Addressing the concrete
components of a client’s actual experience can lead to a more cohesive and realistic sense of self,
with strengths and vulnerabilities, flaws and assets. These feelings may still be concretely
represented in the body, but as they become more inclusive and integrated, negative feelings and
eating symptoms often diminish. An extensive clinical example illustrates how this process can
unfold.
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Listening to words, hearing feelings by F. Diane Barth, LCSWMay 15, 2015DRAFT, ACCEPTED FOR PUBLICATION: PLEASE DO NOT SHARE WITHOUT EXPRESS PERMISSION FROM AUTHOR
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